Annals for Educators - 20 December 2016
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2016)

Web Exclusives20 December 2016Annals for Educators - 20 December 2016FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AFED201612200 SectionsAboutVisual Abstract ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsEffect of Structured Physical Activity on Overall Burden and Transitions Between States of Major Mobility Disability in Older Persons. Secondary Analysis of a Randomized TrialUnlike conditions that invariably progress, mobility disability is a dynamic process characterized by frequent transitions between states of independence and disability over time, especially in older persons. This analysis of a trial involving sedentary older persons assessed the effects of a structured physical activity program on the burden of major mobility disability and the risk for transitions into and out of this state.Use this study to:Ask your learners if and how they assess their patients' abilities to maintain independent mobility. What are the consequences of a loss of mobility (e.g., depression, social isolation)?The accompanying editorial notes that although only about 1 in 5 adults meet physical activity guidelines, and despite overwhelming evidence of its benefits, only one third of adults say their physicians have advised them to exercise. Do your learners discuss exercise with their patients?How would your learners discuss exercise? Would they know what to recommend? How might their recommendations need to be tailored to the individual?The editorial notes a study in which health assistants asked about and recorded patients' exercise habits as a “fifth vital sign.” It resulted in more physician–patient discussions and reductions in health risk factors. Do your learners think this might work in your practice? How would they propose to study such a program in your outpatient practices?Risk for Congenital Malformation With H1N1 Influenza Vaccine. A Cohort Study With Sibling AnalysisVarying risk estimates have been published for congenital abnormalities in the offspring of mothers undergoing vaccination against H1N1 influenza during pregnancy, but did not consider the potential role of confounding by familial (genetic and shared environmental) factors. This population-based national study from Sweden took familial factors into account in order to evaluate whether H1N1 vaccination during pregnancy was associated with offspring malformations.Use this study to:Start a teaching activity with a multiple-choice question. We've provided one below!Ask your learners which immunizations are recommended during pregnancy. Which are contraindicated during pregnancy?Review the 2016 recommended adult immunization schedule from the American Committee on Immunization Practices. Be sure to look at the second figure, which presents recommendations according to medical conditions (including pregnancy).What are the true potential adverse events associated with immunizations?What do your learners know of the inaccurate belief among some patients that there is a link between certain vaccinations and autism? What factors perpetuate such belief (despite evidence to the contrary and the retraction of the original and fraudulent study upon which it may be based)? What are the possible public health consequences of this belief? What role should your learners play in educating their patients and the public? See a recent short discussion of this issue to help frame your discussion.Video LearningAnnals Consult Guys - Postoperative Calf Venous Thrombosis: Location, Location, LocationWatch this short, educational video with your learners, as Geno and Howard (The Consult Guys) discuss what to do about a distal leg thrombosis in a postoperative patient.Use this video to:Ask your learners how they would arrange for serial ultrasonography to assess for propagation of an isolated distal thrombosis. How do they ensure that the studies occur and that the results are acted upon if necessary? What if the follow-up studies are not completed?Ask your learners what the indications are for an IVC filter. What are the acute and long-term risks? Should the availability of “removable” filters alter practice?Our Health Care SystemIs It Time for the USPSTF to Inform—But Not Determine—Coverage?Copay Assistance for Expensive Drugs: A Helping Hand That Raises CostsInnovation–Innovation Tradeoffs in Drug PricingThe uproar over the price of the EpiPen is the latest episode in a longstanding controversy over drug pricing. The first 2 of these short papers discuss ways that drugmakers are currently able, and are trying, to maintain high profits while reducing out-of-pocket costs for patients. The third paper asks whether our current system of incentives is best designed to promote the development of innovative therapies.Use these papers to:Ask your learners whether they think there should limits to how much a manufacturer may charge for a treatment. What are the arguments in favor of or against restrictions?Have your learners heard of industry-sponsored copay assistance programs, such as those described in the second paper? Why might they be helpful for individual patients, yet harmful to society? How do your learners feel about informing patients about such programs and helping them to enroll? Is their responsibility to the patient alone, or might their participation be perpetuating a problem? Do your learners think there is a conflict?What do your learners think would be the best way to approach addressing the high cost of therapies? The authors of the third paper offer ideas. Do your learners agree with them?Patient Experience Must Move Beyond Bad ApplesThe authors of this commentary discuss the shortcomings of current efforts to measure and improve patient experience, which have focused on individual physicians, and instead advocate for a new approach that treats patient experience as primarily a systems property rather than an individual property.Use this essay to:Ask your learners if they have ever had to help a family member navigate a multistep process for medical care. Did the experience alter their view of how easy (or how difficult) it can be for their own patients?What do your learners think are probably the most frustrating aspects for patients in your health care system to navigate their care?Ask your Chief Medical Officer or Chief Quality Officer to discuss your system's patient satisfaction scores with your learners. How are such scores generated?What responsibility do your learners feel they have for the satisfaction of the patients cared for at your health system? What variables are within and outside of their control?Can your learners identify 1 or 2 problematic areas in your system and propose solutions? Is there a way they could become involved in trying to institute solutions? How would they measure if they have been effective?Humanism and ProfessionalismOn Being a Doctor: A Vulnerable MomentDr. Misch recalls how over 35 years earlier he had carried out his attending's order, despite believing it was wrong. And the patient died.Use this essay to:Listen to an audio recording read by Dr. Michael LaCombe.Ask your learners if they have had to carry out orders of more senior physicians that they thought were ill-advised. Did they voice their concerns? How were their concerns received?What should your learners do in such situations? To whom should they turn when they are uncomfortable with what they are being asked to do by those with more medical experience?How do your learners think they will respond if a trainee questions their plans of care for a patient? What would be a constructive and educational way to handle such a situation?Do your learners believe they are capable of recognizing and admitting when the plans of care they made should be reconsidered?MKSAP 17 QuestionA 27-year-old woman at 30 weeks' gestation is evaluated during a routine examination. She is gravida 2, para 1, and delivered her first child vaginally without complications 20 months ago. During her first pregnancy, she received the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine. Her only medication is a daily prenatal vitamin.Findings on physical examination are unremarkable.Which of the following is the most appropriate management of this patient's vaccination status?A. Administer the Tdap vaccine after 36 weeks' gestationB. Administer the Tdap vaccine nowC. Administer the tetanus and diphtheria (Td) vaccine nowD. Administer the Td vaccine after 36 weeks' gestationE. Do not administer the Td or Tdap vaccines during this pregnancyCorrect AnswerB. Administer the Tdap vaccine nowEducational ObjectiveAdminister the tetanus, diphtheria, and acellular pertussis vaccine during pregnancy.CritiqueThis pregnant patient should receive the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine now. To decrease the burden of pertussis in infants (who are at the greatest risk for the disease), the Advisory Committee on Immunization Practices (ACIP) recommends that pregnant women receive a single dose of the Tdap vaccine during each pregnancy, regardless of when they last received either the tetanus and diphtheria (Td) or Tdap vaccine. Because maternal immunity wanes over time, administering the Tdap vaccine between 27 and 36 weeks' gestation is thought to provide optimal protection against pertussis for the infant throughout the newborn period, during which time the child is solely dependent upon maternal antibodies for protection, by boosting the mother's antibody levels. The Td and Tdap vaccines do not contain live elements and are considered safe to administer to pregnant women, as there is no evidence to suggest an increased rate of adverse events in this population.Although the Tdap vaccine can be given at any point during a woman's pregnancy, administering the vaccine between 27 and 36 weeks' gestation is thought to confer maximal antibody protection to newborn infants. It is not advisable to wait until after 36 weeks of pregnancy.The Td vaccine does not provide protection against pertussis and therefore should not be given either now or after 36 weeks' gestation.Withholding vaccination against tetanus, diphtheria, and acellular pertussis during pregnancy is inappropriate. Although this patient received the Tdap vaccine during her first pregnancy, that vaccination is unlikely to provide sufficient protection for her second child at the time of delivery, as antibody levels wane significantly during the first year after vaccination.Key PointPregnant women should receive a single dose of the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine between 27 and 36 weeks' gestation during each pregnancy, regardless of when they last received either the tetanus and diphtheria (Td) or Tdap vaccine.BibliographyCenters for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women—Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep. 2013;62:131-5.Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 20 December 2016Volume 165, Issue 12Page: ED12KeywordsAntibodiesDiphtheriaDisabilitiesExerciseInfantsPertussisPregnancyTetanusToxoidsVaccines ePublished: 20 December 2016 Issue Published: 20 December 2016 Copyright & PermissionsCopyright © 2016 by American College of Physicians. All Rights Reserved.Loading ...